MedPage: Healthcare Issues Popping Up on State Ballots in November

Voters being asked to consider tobacco taxes, other initiatives

Although the nation’s election focus has been on all things presidential, there are plenty of state ballot issues to think about, including many involving healthcare. MedPage Today has put together a sampling of the healthcare ballot issues voters will be considering in the upcoming election.

Tobacco, Marijuana Initiatives

Several states, including California, Colorado, Missouri, and North Dakota, have initiatives that ask voters to increase the state tobacco tax. California’s Proposition 56 would increase that state’s tobacco tax by $2, while Colorado’s would go up by $1.75 under that state’s initiative.

“We used to be ahead of the curve on this, and over the years we have drifted downward to the bottom half of the states” in terms of the size of the tobacco tax in California, Carla Kakutani, MD, chair of the legislative committee at the California Academy of Family Physicians (CAFP), said in a phone interview.

The academy is endorsing the proposal for two reasons: “Anything that can decrease smoking, we’re in favor of; research has shown that if the cost of a cigarette pack is increased by 10%, you’ll see a decrease in teen smoking by 7%,” said Kakutani. In addition, the measure includes electronic cigarettes, “so that would make it at least somewhat more difficult for kids to get ahold of [those].”

In Colorado, the tobacco tax hasn’t been raised since 2004, noted James Fenton, MD, a pulmonologist at National Jewish Health in Denver. “We realized that Colorado had one of the lowest tobacco taxes in the country – $0.84 a pack — essentially a dollar below the national average [tax] for nontobacco-producing states,” he said in a phone interview. And yet, “… [we have] found tobacco taxes to be an effective deterrent for smoking … They are found to be the single most effective way to reduce tobacco use.” Unlike California, however, Colorado’s initiative applies only to tobacco products, not e-cigarettes or marijuana, Fenton added.

North Dakota’s proposed tobacco tax would set up a tobacco trust fund to fund certain veterans’ programs; the tobacco tax revenue would be split among the trust fund, the general state fund, and the state’s community health fund.

Marijuana also appears on the ballot in several states, with four — Arkansas, Florida, North Dakota, and Oklahoma — asking voters whether they want to legalize marijuana for medical use, or to expand the current medical marijuana law. “Arkansas actually has two competing medical marijuana initiatives on the November ballot: The Arkansas Medical Marijuana Act (restricts access to state-approved dispensaries) and the Medical Cannabis Act (patients who have received the necessary approval from physicians and the state can grow marijuana plants on their own),” the American Academy of Sleep Medicine (AASM) noted on its website. “Should both initiatives win approval, the one with the highest number of ‘yes’ votes will supersede the other.”

In addition, voters in five states — Arizona, California, Maine, Massachusetts, and Nevada — are being asked to legalize marijuana for recreational use, according to the National Conference of State Legislatures’ Ballot Measure Database.

Curbing the Cost of Rx Drugs

California will be considering a measure aimed at reducing the high cost of some prescription drugs. The measure, known as Proposition 61, would cap the prices paid by state-run health programs at no more than what the Department of Veterans Affairs pays for its drugs. The measure has wide support among state voters, including 77% of Democrats and 70% of Republicans, according to Politico. And it has been an expensive battle, with the measure’s opponents spending more than $60 million to defeat the measure compared with $9.4 million in spending by proponents.

The CAFP has not taken a position on the bill. “It feels like we do not have enough information one way or another,” said Kakutani. “We have been discussing where we should weigh in on drug pricing. I think 61 is well-intentioned but may have unintended consequences.”

Medical Liability Reform

Arkansas’ Issue 4 addresses malpractice lawsuits: it would limit attorney contingency fees in malpractice cases to 33%, and would have the state legislature enact a cap on non-economic damage awards in malpractice cases, noting that ‘such a measure may never be smaller than $250,000.'”

Universal Healthcare

One state, Colorado, is asking its voters whether they want universal healthcare. The ballot measure, known as Amendment 69, would get rid of the state’s Affordable Care Act (ACA) exchanges and would replace most private insurance plans; however, it is not considered a single-payer plan and would not eliminate government programs such as Medicare, TriCare, or the Department of Veterans Affairs (VA) health system in the state — instead, it would act as supplemental insurance for people in those programs. People also would still be able to buy private insurance, although it is thought to be unlikely that they would want to pay to duplicate the new program’s benefits.

The program, known as ColoradoCare, would be supervised by a board of 21 people and would be financed through individual and employer taxes, totaling a 10% tax increase overall. Patients would be able to choose their own primary care physicians, and many deductibles and copays would be eliminated.

The measure’s proponents argue that having a universal system would cut out insurance company overhead and therefore lower costs overall. But opponents are concerned about how the measure would affect providers. “Competition between health insurers plays a critical function in our state’s healthcare system by helping to drive down costs,” the Colorado Hospital Association wrote in a position paper opposing the amendment. “Working with multiple insurers provides hospitals with the negotiating power they need to ensure reimbursements are sufficient.”

Physicians for a National Health Program (PNHP), an organization supporting single-payer healthcare, notes on its website that the proposal has many strengths, but that because some private and other public payers would still be in the system, “[the proposal] sacrifices much of the administrative savings that could be realized through a true single- payer reform because providers would have to maintain much of their current cost-tracking and billing apparatus in order to apportion costs among the multiple payers.” PNHP has not taken a position on the proposal.

Physician-Assisted Suicide

A measure on the ballot in Colorado would allow patients who have been diagnosed with a terminal illness — defined as having less than 6 months to live — to request a prescription from their doctor to hasten their death.

The law would require two physicians to confirm the prognosis, and to confirm that the patient has gotten information about other options. It would also require patients to undergo a mental health evaluation if either doctor believes the patient isn’t mentally capable of making the decision, and it exempts from civil or criminal liability anyone who helps the patient access the medication or who is present when it is self-administered.

Jennifer Popik, JD, director of medical ethics at the National Right to Life Committee, which opposes the measure, noted that the Colorado legislature has rejected nearly identical bills this year and last year, arguing that they were too dangerous. “We agree that these assisted suicide laws pose too great a threat to vulnerable populations no matter what so-called ‘safeguards’ they might contain,” she wrote in an email. “We join many typically politically unaligned groups opposing these measures, including disability rights groups, the American Medical Association, prolife and church groups, and others.”

Although proponents claim that such a law would simply provide another medical option, “there is evidence from the state living with a nearly identical version of this law the longest — Oregon — that these laws have expanded far beyond those we think of as terminally ill — including diabetics and those with HIV and hepatitis, because without treatment they could die within 6 months,” she continued. “So many may be giving up unnecessarily on many more good years of life.”

Compassion & Choices, an aid-in-dying organization, supports the measure. “End-of-life decisions are best left to dying people, consulting their families, their faith, and their doctors – not the government,” Jessica Grennan, campaign manager of the Yes on Colorado End-of-Life Options effort, said in a press release posted on the organization’s website. “This proposal takes government out of these personal decisions and allows patients to make their own choices about their life based on their health, their family’s input, and their personal religious beliefs.”

Biomedical Research

On the Montana ballot, Initiative 181 would establish a state Biomedical Research Authority “to oversee and review grant applications for the purpose of promoting the development of therapies and cures for brain diseases and injuries and mental illnesses, including Alzheimer’s, Parkinson’s, brain cancer, dementia, traumatic brain injury, and stroke.” Grants would be funded by state general obligation bonds.

Safer Movie Sex

Proposition 60 on the California ballot would require the use of condoms during filming of sexual intercourse, and would require producers of adult films to “pay for performer vaccinations, testing, and medical examinations related to sexually transmitted infections.” Producers also would have to post the condom requirement at film sites, and the initiative would impose liability on producers who fail to comply, as well as on agents “who knowingly refer performers to noncomplying producers.”

Reproductive Rights

One issue notably missing from this year’s state ballots is reproductive rights. Organizations on both sides of the abortion debate said they were not following any ballot issues on the topic this time around.

This article, originally posted on Oct. 6 at 06:00 ET, has been updated with new information.

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